Huge Extrapleural Hematoma After a Blunt Chest Trauma: An Unusual Presentation

Abstract Massive extrapleural hematoma secondary to blunt chest trauma is exceedingly rare especially in nonanticoagulated patients. Significant amounts of blood can be sequestered between parietal pleura and the endothoracic facia leading to ventillatory and circulatory disturbances and even death. We report a case of a huge extrapleural hematoma in a non-anticoagulated 70-year-old patient secondary to blunt chest trauma. Etiology, surgical and treatment implications of this injury are briefly discussed.     

胸部创伤外科的历史回顾与展望

胸部创伤外科最早的文献记录为公元前3000年。至15世纪以前,胸部创伤外科只能用简单方法处理胸壁伤口;至20世纪初,步入胸腔内器官和损伤治疗;20世纪50～80年代,现在胸部创伤外科已具备完整的形态与完善的内涵。20世纪90年代至今,新技术如微创手术、新理念如快速康复外科、损伤控制性手术、新材料、多学科协作及信息网络和转化医学的发展改善了胸部创伤外科患者结局,并将促进未来胸部创伤外科的学科发展。     

Undiagnosed Myocardial Tear Blocked by an Omental Plug: Potentially Lifethreatening Condition

Abstract Blunt chest trauma carries a high mortality when associated with cardiac rupture. Rapid diagnosis represents a true challenge for clinicians, with CT scan examination playing a central role. We report a case of a traumatic myocardial tear, plugged by the greater omentum through a diaphragmatic rent in an hemodynamically stable patient. This condition, identified during laparoscopy, was not suspected preoperatively at both clinical examination and CT. This case illustrates that a transparietal cardiac rupture can be sealed off by surrounding structures. This phenomenon explains why CT can be unable to detect traumatic cardiac rupture, with the potential risk of a delayed fatal bleeding. This case also emphasizes the risk of using laparoscopy in traumatic diaphragm rupture repair.     

Delayed Presentation of a Tracheoesophageal Fistula After Blunt Chest Trauma

Traumatic tracheoesophageal fistula is an uncommon injury after blunt chest injury. Rapid deceleration against the steering wheel during a high-speed motor vehicle crash is the usual mechanism of injury. Previous reports document few cases of delayed diagnosis and repair of tracheoesophageal fistula. We report a case of delayed diagnosis of tracheoesophageal fistula more than 20 years after the original trauma and describe the subsequent operative repair.     

Thoracoscopic Retrieval of Foreign Bodies After Penetrating Chest Trauma

Video-assisted thoracic surgery or thoracoscopy has proved to be valuable in many settings in thoracic surgery. The use of video-assisted thoracic surgery in trauma has been limited, especially with respect to penetrating trauma. We report the use of thoracoscopy to remove intrathoracic fragments of glass and avert the need for a thoracotomy.     

The Advanced Trauma Operative Management course—a two student to one faculty model

Background

The internationally recognized Advanced Trauma Operative Management (ATOM) course uses a 1:1 student-to-faculty teaching model. This study examines a two student to one faculty ATOM teaching model.

Materials and methods

We randomly assigned 16 residents to four experienced ATOM faculty members. Half started with the one-student model and the other half with the two-student model and then switched using the same faculty. Students and faculty completed forms on the educational value of the two models (1 = very poor; 2 = poor; 3 = average; 4 = good; and 5 = excellent) and identified educational preferences and recommendations.

Results

We assigned educational values for the 13 procedures as follows: All faculty rated the one-student model as excellent; six members rated the two-student model as excellent, and seven as good. Students rated 50%–75% as excellent and 12%–44% as good for the two-student model, and 56%–81% as excellent and 12%–44% as good for the one-student model. Given resource constraints, all faculty and 88% of students preferred the two-student model. With no resource constraints, 75% of students and 50% of faculty chose the two-student model. All faculty and students rated both models “acceptable.” Overall, 81% of students and 50% of faculty rated the two-student model better. All faculty members recommended that the models be optional; 94% of students recommended that they be either optional (50%) or a two-student model (44%). Performing or assisting on each procedure twice was considered an advantage of the two-student model.

Conclusions

The two-student teaching model was acceptable and generally preferred in this study. With appropriately trained faculty and students, the two-student model is feasible and should result in less animal usage and possibly wider promulgation.     

Evaluation of the Trauma-Man? Simulator for Training in Chest Drain Insertion

Abstract Background: The Trauma-Man^? simulator (Simulab, USA) was announced by the American College of Surgeons as a legitimate alternative to the advanced trauma life support (ATLS) animal surgical skill station. The aim of this study was to evaluate chest drain insertion training using the simulator. Methods: Twenty-four experienced physicians and 42 ATLS course participants performed chest drain insertion using the simulator. Additionally, the ATLS course trainees performed the task in the animal skills laboratory. Following training they all completed a subjective questionnaire. Results: Experts rated the various steps required for chest drain insertion similar to the human equivalent, with median scores of 4 or 5 (scale of 1–6) for all steps and recommended the use of the simulator for the training of novice doctors in performing the procedure (score 5.5 ± 0.8, median 6 in a scale of 1–6). Experts recommended that the area allotted for chest drain insertion in the simulator will be modified in the cephalad direction to correspond with the guidelines of chest drains insertion. ATLS course participants found the simulator superior to the animal model only in teaching anatomical landmarks, whereas the animal model was found to be superior in teaching tissue dissection and chest drain fixation. Conclusion: The Trauma-Man^? simulator is an efficient training tool for the chest drain insertion. Minor changes are recommended for the enhancement of the simulators' realism.     

Pneumomediastinum and Subcutaneous Emphysema Unusual Complications of Blunt Facial Trauma

We described a rare case of pneumomediastinum following an isolated facial trauma. Traumatic pneumomediastinum is usually secondary to a blunt or penetrating neck, chest or abdominal trauma.     

Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk

Introduction

A child's risk of developing cancer from radiation exposure associated with computed tomography (CT) imaging is estimated to be as high as 1/500. Chest CT (CCT), often as part of a “pan-scan,” is increasingly performed after blunt trauma in children. We hypothesized that routine CCT for the initial evaluation of blunt injured children does not add clinically useful information beyond chest radiograph (CXR) and rarely changes management.

Methods

Pediatric (<15 y) trauma team evaluations over 6 y at an academic Level I trauma center were reviewed. Demographic data, injuries, imaging, and management were identified for all patients undergoing CT. Effective radiation dose in milliSieverts (mSv) was calculated using age-adjusted scales.

Results

Fifty-seven of 174 children (33%) undergoing CT imaging had a CCT; 55 (97%) of these had a CXR. Pathology was identified in significantly fewer CXRs compared with CCTs (51% versus 83%, P < 0.001). All 7/57 (12%) emergent or urgent chest interventions were based on information from CXR. In 53 children (93%), the CCT was ordered as part of a pan-scan, resulting in a radiation dose of 37.69 ± 7.80 mSv from initial CT scans. Radiation dose was significantly greater from CCT than from CXR (8.7 ± 1.1 mSv versus 0.017 ± 0.002 mSv, P < 0.001).

Conclusions

Clinically useful information found on CCT had good correlation to information obtained from CXR and did not change patient management, however, did add significantly to the radiation exposure of initial imaging. We recommend selective use of CCT, particularly in the presence of an abnormal mediastinal silhouette on CXR after a significant deceleration injury.     

Chylothorax Resulting from a Penetrating Injury of the Neck: a Case Report

Abstract  Chylothorax is characterized by an accumulation of lymphatic fluid in the pleural cavity due to compression or loss of integrity of the thoracic duct for any reason. It is frequently secondary to intrathoracic malignancies and iatrogenic trauma. Thoracic duct injury and resulting chylothorax, due to penetrating injuries of the neck, are very rare. This report presents a patient with chylothorax associated with penetrating neck trauma, who was successfully treated, and provides discussion on this very rare case in the light of the available literature.     

Laryngotracheal Trauma: Up-to-date Report of Two Cases of a Challenging Problem

Abstract Background: Laryngotracheal trauma is still a challenging problem to the emergency surgeon. Prompt diagnosis and correct classification are mandatory in order to plan the treatment. Methods: Two particular cases of an upper airway trauma are presented. Case 1 refers to a 53-year-old woman with a blunt fracture of the thyroid cartilage. Case 2 is a 43-year-old man with a penetrating tracheal trauma and cervicomediastinal emphysema. Results: Patient 1 was treated conservatively, by intravenous fluid, antibiotics and steroids, and had a good outcome. Patient 2 had a progressive respiratory distress and underwent surgical repair of the tracheal lacerations. Follow-up examination revealed a good healing of the injuries. An up-todate information about the upper airway trauma and its management is given. Conclusion: Upper airway trauma requires a rapid evaluation and establishment of the airway. Subsequent imaging may address the correct treatment by allowing a precise classification of the injury. Long-term results may be good in the majority of the patients.     

中国创伤救治培训护理版课程培训实践

目的 探讨中国创伤救治培训护理版课程培训的方法及效果。方法 成立培训小组,通过专家访谈、文献分析及小组讨论构建中国创伤救治培训护理版课程,组建讲师团队,对975名护士进行理论授课和工作坊相结合的培训,课程结束后进行考核和满意度调查。结果 897名护士完成考评,培训后学员理论综合考核成绩较培训前显著提升（P＜0.05）。学员对培训的满意度评分均在4分以上。结论 中国创伤救治培训护理版课程培训可提高护士创伤相关知识,从而提升创伤救治能力。     

胸部创伤损伤严重度评估及死亡原因分析

目的探讨胸部创伤的死亡原因及损伤严重度评估，以提高胸部创伤的诊断及治疗水平。方法回顾性分析我院687例胸部创伤的临床资料，并根据治疗结果（分为生存组、死亡组）、有无合并伤（分为单纯胸伤组、多发伤组）以及是否有胸膜腔与外界沟通（分为闭合伤组、开放伤组）分组进行修正创伤评分（RTS）、简明损伤定级（AIS）、损伤严重度评分（ISS）和计算生存概率（PS），比较不同组间的损伤严重程度，分析死亡的高危险因素。结果闭合伤组488例，其中死亡21例，死亡原因为原发性颅脑损伤10例，急性呼吸衰竭6例，多器官功能不全综合征（M（）DS）4例，低血容量性休克1例；开放伤组199例，其中死亡9例，死亡原因为低血容量性休克9例。创伤评分各指标在生存组、死亡组间差异有统计学意义（GCS：t=4．648，P=0．000，RTS：t=4．382，P=0．000，胸AIS：t=2．296，P=0．027，ISS：t=4．871，P=0．000；Ps：t=4．254，P=0．000）；单纯胸伤组与多发伤组胸AIS差异无统计学意义（t=0．723，P=34．567），但RTS（t=2．553，P=0．032），ISS（t=10．776，P=0．000），Ps（t=3．868，P=0．007）差异有统计学意义；在闭合伤生存组、开放伤生存组间，虽然RTS（t=3．161，P=0．007），ISS（t=4．118，P=0．005）差异有统计学意义，但Ps差异无统计学意义（t=0．857，P=97．453），而在闭合伤死亡组、开放伤死亡组间差异均有统计学意义（GCS：t=4．016，P=0．001；RTS：t=3．168，P=0．006；胸AIS：t=2．303，P=0．043；ISS：t=4．218，P=0．002；Ps：t=4．624，P=0．001）。创伤死亡率随创伤评分增高而增高，全组ISS值在20～25时，死亡率为10．7％，在ISS值相同时，开放伤组死亡率较闭合伤组高。结论胸部创伤应用创伤评分有助于判断损伤严重度，指导临床救治；闭合伤死亡原因较开放伤复杂；严重创伤     

Finnish Trauma Audit 2004: current state of trauma management in Finnish hospitals

There is great variation in the organisation of trauma care in European countries. The state of trauma care in Finnish hospitals has not been appropriately reviewed in the past. The aim of the present study conducted by the Finnish Trauma Association (FTA) was to assess the number of Finnish hospitals admitting severe trauma patients, and to evaluate the organisation and training of trauma care in those hospitals. In 2004, a telephone survey to all the Finnish hospitals was conducted, and information on the number of severe trauma patients treated per month, the organisation of acute trauma care, and the existence of multidisciplinary trauma care training was collected. Thirty-six Finnish hospitals admitted trauma patients. The range of estimated number of severely injured trauma patients treated in individual hospitals per month varied from 0.5 to 12, resulting in an estimated number of 1000-1300 patients with severe trauma treated in Finland every year (19-25/100.000 inhabitants). About 20% of the hospitals had a trauma team, and 25% had a systematic trauma education program. Only one hospital had established multidisciplinary and systematic trauma team training. The case load of severe trauma patients is low in most Finnish hospitals making it difficult to obtain and maintain sufficient experience. Too many hospitals admit too few patients, and only a few hospitals have been working on updating their trauma management protocols and education. There is an obvious need for leadership, discussion, legislation and initiatives by the professional organisations and the government to establish a modern trauma system in Finland.     

Complex Hepatic Injuries: an Audit from a Tertiary Center

Abstract Background:  Nonoperative management is being increasingly employed in the management of blunt hepatic injuries. Patients and Methods:  We analyzed patients with complex hepatic injuries over a period of 10 years (1996–2006). Results:  Two hundred and ten patients with blunt hepatic injury were admitted and 103 patients had complex liver injuries. The predominant mode of injury was road traffic accidents in 91.2%. The grade distribution of liver injuries was grade III (72.8%), grade IV (23.3%) and grade V (4.9%). Twenty-four patients (23.3%) underwent surgery for persistent hemodynamic instability, persistent fall in hemoglobin level, bile leaks and intra-abdominal collection with sepsis. Associated intra-abdominal injuries were present in 19.4%, and 58.4% had associated extra-abdominal injuries. The operative procedures included hepatectomy (1), suture hepatorraphy (12), T-tube drainage for bile duct injuries (5), perihepatic sponge and gel foam packing (9), liver abscess drainage (3), and resection and debridement of liver tissue in six patients. The mortality and morbidity in this series was 10.7 and 56.4%, respectively. Multiorgan failure was present in 5, single organ failure in 37, sepsis in 24, biliary complications in 16 and intra-abdominal collection in 17 patients. Endoscopic management for bile leaks was performed in five patients, image-guided pig-tail drainage for abscesses in 11 patients, while angioembolization was done in two patients for right hepatic artery bleed. The mortality was not significantly different in surgical and nonoperative groups but operated patients had significantly higher morbidity. Conclusions:  Complex liver injuries can be managed successfully with conservative treatment in majority, with low mortality and acceptable morbidity. Surgery is reserved for selected indications.     

Validation of thoracic injury rule out criteria as a decision instrument for screening of chest radiography in blunt thoracic trauma

BackgroundThoracic injury rule out criteria (TIRC) were first introduced as a decision instrument for selective chest radiography in blunt thoracic trauma in 2014. However, the validity of this model has not been assessed in other studies. In this regard, the present survey evaluates the validity of TIRC model in a multi-center setting.MethodsIn this cross-sectional study, clinical presentations and chest radiograms of multiple trauma patients referring to 6 educational hospitals in Iran were evaluated. Data were gathered prospectively during 2015. In each center, data collection and interpretation of radiograms were conducted by two different emergency medicine specialists. Measures were then taken for assessment of discriminatory power and calibration of the model.ResultsData from 2905 patients were gathered (73.17% were male; the mean age was 33.53 ± 15.42 years). Area under the receiver operating characteristics curve of the TIRC model for detection of thoracic traumatic injuries was 0.93 (95%CI: 0.93–0.94). Sensitivity and specificity of the model were 100 (98.91–100) and 67.65 (65.76–69.45), respectively. The intercept of TIRC calibration plot was 0.08 (95%CI: 0.07–0.09), and its slope was 1.19 (95%CI: 1.15–1.24), which are indicative of the model being perfect in detecting presence or absence of lesions in chest radiograms.ConclusionThe findings are corroborative of external validation, good discrimination, and proper calibration of TIRC model in screening of multiple trauma patients for obtaining chest radiograms.